EOB — Medicare Advantage HMO. Plan: Health First MA-HMO. Member: MEM-65003. Date of Service: 2026-04-11. Provider: Mountain Regional Medical Center (NPI 0000000006). Service: Emergency Department evaluation level 5 (CPT 99285), abdominal CT (CPT 74177). Billed: $4280. Allowed: $0. Paid: $0. Member liability per claim: $4280. CARC 242 — Services not provided by network/primary care providers.
Strong appeal: Emergency services at any facility are covered under the MA plan as in-network when the member presents for emergency evaluation under the prudent-layperson standard (42 CFR §422.113 + Section 1852(d)(3) of the Social Security Act). File Standard Reconsideration under §422.582 within 60 days; cite §422.113. The plan must cover emergency services at out-of-network facilities at the in-network cost-sharing rate. Member should not be balance-billed during appeal.
OON denials for emergency care are categorically improper for MA plans. The 'prudent layperson standard' guarantees emergency-services coverage regardless of network status. This is one of the cleanest OON appeals to win.
Per-scenario model output is captured during a leaderboard Run all. Trigger a run from the leaderboard to see each variant’s output side-by-side with the ground truth here.
To run this scenario through the live cockpit, copy the EOB above into the cockpit and watch the streamed triage in context.